Presentation
Persistent left-sided headaches for months without focal neurology or meningism.
Patient Data
Multiple pachymeningeal-based peripherally-enhancing lesions are present along the inferior aspect of the right cerebral hemisphere, the posterior petrous ridge bilaterally, and adjacent to the left petrous apex along the lateral aspect of the cavernous sinus and the floor of the middle cranial fossa medially. There are further smaller lesions overlying the right temporal pole and along the inferolateral aspect of the left frontal lobe. All lesions are 1-2 cm in size and demonstrate relatively low T2 signal centrally. Adjacent T2 hyperintense parenchymal signal is nonenhancing and in keeping with edema. The parenchymal change within the inferior right cerebellar hemisphere is associated with some restricted diffusion. There is no definite inflammatory change within the orbital apex. Although the lesion adjacent to the left petrous apex is inseparable from the left trigeminal nerve within the pre-pontine cistern, there is no convincing cranial nerve enhancement. There is associated nodular heterotopia along both lateral ventricular margins. The most likely etiology is an inflammatory pachymeningeal disease, with differential diagnoses including sarcoidosis, vasculitis or atypical infection. Hematologic or metastatic disease are also possible causes for these changes, but are less likely.
Case Discussion
This middle-aged heterosexual man with no history of immune suppression presented multiple times over the course of a few months to the emergency department and the local general practitioner with recurrent predominantly left-sided intermittent headaches. Non-specific changes on non-contrast CT brain (not uploaded) raised the possibility of subacute cerebral infarction and a raised ESR pointed the managing clinicians towards a presumptive diagnosis of vasculitis. Following the presented MRI findings, serological and cerebrospinal fluid testing yielded a positive result to anti-treponemal antibodies, in keeping with neurosyphilis. HIV testing and vasculitis serological panel were negative. The patient went on to receive long term intravenous antibiotics as per best practice and remains under ongoing follow-up with the neurology and infectious diseases teams.